Topic №4: Birth trauma

The prevalence of surgical diseases in pregnant women is approximately 2: 1000. The principles of treatment of surgical diseases are the same as those of non-pregnant ones. The prognosis for the mother and fetus depends more on the severity of the disease than on the volume and duration of the operation. During pregnancy, the clinical picture of acute diseases of the abdominal cavity changes, which greatly complicates their diagnosis. A detailed study of the anamnesis and laboratory data, as well as a thorough physical examination, help to diagnose correctly and resolve the need for hospitalization and emergency surgical intervention.

Acute appendicitis.

The increase in the size of the uterus changes the location of the appendix, which causes a variety of clinical manifestations of acute appendicitis.

 

The risk of gangrenous appendicitis and perforation of the appendix in the third trimester of pregnancy is higher (69%) than in I and II (31%). Perforation perinatal mortality reaches 28%, and in her absence, only 5%. In this regard, if you can not exclude acute appendicitis, an emergency surgical intervention appendectomy is indicated. With the timely surgical treatment of acute appendicitis, the prognosis is favorable.

 

Since the risk of an erroneous diagnosis is high, in the first trimester of pregnancy, the most convenient surgical approach is median laparotomy. Regardless of whether the appendix is ​​changed or not, it is removed. With peritonitis and appendicular abscess, the abdominal cavity is drained and antibiotics of a wide spectrum of action are prescribed. With full term pregnancy and diffuse peritonitis, a caesarean section is indicated. With gangrenous appendicitis, if the risk of spreading the inflammatory process to the uterus is high, it is extirpated.

Complications of appendectomy: premature birth and wound infection, therefore, usually requires tocolytic therapy and the imposition of delayed sutures on the anterior abdominal wall.

 

Acute pancreatitis.

The prevalence among pregnant women is 1 case per 3000-10000. The disease is usually associated with cholelithiasis and is more likely to develop in the third trimester of pregnancy.

Pregnancy does not affect the clinical picture of acute pancreatitis. In 70-90% of cases, nausea and vomiting occur. Often there is acute, intense and prolonged pain in the epigastrium, radiating into the back. Pancreatic necrosis may be complicated by hemorrhage in the retroperitoneal tissue. This is accompanied by cyanosis of the lateral surfaces of the abdomen and cyanosis in the peri-pooch area.

Differential diagnosis is performed with acute appendicitis, exfoliating aneurysm of the abdominal aorta, intestinal obstruction, acute cholecystitis, diabetic ketoacidosis, peptic ulcer, pyelonephritis, parainfrit, perforation of the hollow organ and renal colic.

In laboratory studies, the following changes are noted:

1. mild hyperbilirubinemia;

2. leukocytosis is higher than 15-30X10%;

3. Serum amylase level is higher than 2000 U / l.

Conduct an overview radiography of the abdominal cavity (exclude the accumulation of free gas). Ultrasound is used to detect calcification, edema and false pancreatic cysts. If the diagnosis is confirmed, treat acute pancreatitis and prevent its frequent complications: hypocalcemia, hypovolemia, hypomagnesemia and hyperglycemia. In addition, with acute pancreatitis, the risk of acute arterial hypertension, DIC syndrome, ARDS, bleeding and the formation of false pancreatic cysts is high.

Treatment is the same as non-pregnant. With conservative treatment, the disease is usually resolved within 3-7 days. Anesthesia, infusion therapy and careful monitoring of calcium, magnesium and glucose in the serum are performed. Abolish the intake of food, liquids and medicines inside.

 

Acute cholecystitis.

 

The second most common (after acute appendicitis) is the chi-rurgic disease in pregnant women. Attacks of biliary colic requiring cholecystectomy are rarely observed. The disease most often develops on the background of cholelithiasis due to blockage of the cystic duct with stones. In 3.5-11% of pregnant women, cholelithiasis is asymptomatic, and stones are accidentally detected with ultrasound.

 

Diagnosis of acute cholecystitis and cholelithiasis in pregnant women is the same as in non-pregnant women. The localization and character of pain in pregnant women does not change, however, local symptoms are usually not very pronounced. Acute cholecystitis in pregnant women should be differentiated with acute appendicitis, peptic ulcer and other surgical diseases. Pregnancy does not affect the clinical picture of acute cholecystitis. The disease manifests itself as nausea, vomiting, and acute pain in the right upper quadrant, which can irradiate in the back. In laboratory studies, the following changes are observed.

 

Treatment. Conservative therapy: aspiration of the stomach contents through the nasogastric tube, infusion of fluids, analgesics. Indications for surgical intervention are put in the ineffectiveness of conservative treatment, repeated attacks, mechanical jaundice, suspicion of perforation of the gallbladder or the development of other complications. If there is a possibility to postpone the operation, it is better to perform a cholecystectomy in the second trimester of pregnancy (after 17-18 weeks), since in I trimester the risk of spontaneous abortion and teratogenic action of general anesthetics is high, and in the III trimester the operation is technically more difficult. In recent years, if necessary, performed laparoscopic cholecystectomy in the period of 13-23 weeks of pregnancy.

 

A peptic ulcer.

It occurs in 1 out of 4,000 pregnant women. It is believed that the risk of the disease during pregnancy decreases.

Clinical manifestations of peptic ulcer disease include dull, aching epigastric pain, sometimes with irradiation in the back. The pain usually goes away after eating food or antacids. Sometimes there is vomiting with an admixture of unchanged or altered blood (the latter is similar to the coffee grounds). Assign a gastroscopy. This study helps confirm the diagnosis, and also conduct differential diagnosis between peptic ulcer and other conditions requiring treatment.

Treatment. Exclude smoking and alcohol. Assign antacids, sucralfate and H2-blockers. Liquid antacids are used in a dose of 30 ml orally every 2-3 hours. Before the appointment of sucralfate or H2-blockers necessarily conduct gastroscopy.

With gastrointestinal bleeding, the risk of fetal death and the development of complications in the mother is dramatically increased. Massive bleeding during pregnancy is an indication for emergency surgery.

Intestinal obstruction.

Intestinal obstruction in pregnant women can be caused by spikes, curvature of the intestine, intussusception and infringement of the hernia (in decreasing order of frequency). Urgent surgical intervention is required. Preoperative preparation (aspiration of stomach contents through a nasogastric tube and treatment of metabolic disorders) should take as little time as possible. After restoring the patency of the intestine, a thorough audit of the abdominal cavity organs is performed.